Child's Enrollment Form

CHILD'S ENROLLMENT FORM

Program: (Circle one) Saturday Respite Program or Vacation Program: December February April All
Child's Name: / Eye Color: / Skin Color:
Home Address: / Hair Color: / Height:
Telephone: / Sex: / Weight:
Parent Email Address: / Age at Admission:
Date of Birth: / Primary Language:
Identifying Marks:
Allergies / special diets:
Primary Disability:

PARENT/GUARDIAN INFORMATION:

Parent/Guardian Name: / Parent/Guardian Name:
Relationship to child: / Relationship to child:
Home Address: / Home Address:
Home Telephone #: / Home Telephone #:
Cell Phone: / Cell Phone:

IN CASE OF EMERGENCY, IF PARENT OR GUARDIAN CANNOT BE REACHED, PLEASE NOTIFY:

(WE MUST HAVE EMERGENCY CONTACTS FOR ALL APPLICANTS; IT NEEDS TO BE SOMEONE WHO CAN PICK UP THE APPLICANT IF ILL OR INJURED).

NAME:

RELATIONSHIP TO APPLICANT:

ADDRESS:

HOME PHONE : ( ) WORK PHONE: ( )

CELL PHONE: ( )

Do you give permission for child to be released to this person? YES NO

NAME:

RELATIONSHIP TO APPLICANT:

ADDRESS:

HOME PHONE : ( ) WORK PHONE: ( )

CELL PHONE: ( )

Do you give permission for child to be released to this person? YES NO

Personal Information:

Yes / No
Yes / No
Yes / No

Does the applicant need help with feeding?

Please Specify:

Is the applicant able to dress themselves?

Please Specify (buttons, zippers, etc):

Is the applicant independent in toileting skills?

If no, please specify:

Please note all methods the applicant uses to communicate:

Talking Gestures Communication board or book

Alternative/augmentative communication used (describe): ______

Sign Language- list signs he/she understands: ______

List signs he/she uses: ______

What kinds of activities does applicant enjoy and/or do well?

List school subjects, books, songs applicant likes: _____

What works as motivation for applicant (things he/she likes to do, small tokens, etc)? _____

What activities particularly frustrate the applicant?

______

For each behavior, please describe how the family and the school handle/respond to the behavior. Also note if behavior occurs only at home, only at school or at both home and school.

BehaviorFamily ResponseSchool Response

What are your goals for the applicant in the life skills, social skills, and transition/academic support sections of this program? ______

What else should we know about the applicant that would help us to know how to work with him or her better?

______

ADDITIONAL INFORMATION:

Child's Physician/Clinic:
Address: / Phone:
Chronic health conditions:
Special limitations or concerns:

CurrentSchool: School Address:

I certify that documentation of physical examination and immunizations in accordance with public school health requirements, and lead poisoning screening in accordance with public health requirements are on file at my child's school.

Parent/Guardian initials: ______

Parent/Guardian Signature Date

Photographic Release - Please Read and Sign Below - Publicity photographs for public distribution, i.e., newspapers, brochures and The PaulCenter website are taken during The PaulCenter programs. Please indicate whether or not your son/daughter may be included in these photographs and his/her name used.

Please sign only one of the following:

I agree that my son/daughter may be included in publicity photos and his/her name used.